Families In Crisis: NICU Nurses

Families in Crisis
We as NICU nurses are given a very difficult task of caring for the most fragile population…as well as ministering to the most vulnerable families in the hospital.

Families in Crisis
Neither of these tasks is easy, yet we have to perform them simultaneously.
It is difficult and stressful…and also rewarding. Here we will focus on the family.

Objectives
 Recognition of the unique psychological tasks

and stressors of NICU families
 Description of assessment strategies for families in crisis
 Discussion of the impact on and interventions for successful family-infant bonding in NICU

Definition of Crisis
 Temporary disequilibrium

 A problem or transitional phase so stressful

that normal
coping strategies may not work
Key Point: The premature birth or the birth of a sick infant catapults a family into crisis

Major Psychological Tasks for NICU Families
Acknowledgement of failure to deliver a

term infant
Maternal guilt
Perceived (or real) blaming by others

Psychological Tasks
 Preparation for possible loss of infant

Possibility of death
Hoping for survival

Fear of what survival may bring

Psychological Tasks
Adaptation to NICU environment
Special entry/access procedure
Intimidating setting
Environmental/equipment barriers
Absence of the social support that

accompanies term birth & homecoming

Psychological Tasks
 Establishment of a healthy relationship

with infant
Bonding vs. on-going threat of loss
Parental competence vs.incompetence
Absence of reciprocal relationship from infant

Psychological Tasks
Preparation for discharge
 Parent concern about ability to care

for infant
Risk for maladaptive parenting
Failure to bondNeglect
Over-protectiveVulnerable Child
Syndrome

Assessment of Coping Strategies:
Factors that Influence Coping
Socioeconomic status
 Limited resources (transportation issues)
 Lack of role models

Adolescent pregnancy
Presence/absence of support

Mother’s medical condition

More Factors Affecting Coping
Cultural
 Perfect vs. imperfect child
 Role of the male vs. female in

communication & decision making
 Visitation

Assessment of Parents’
Emotional States
Grief
 Response of sadness/sorrow to the loss of a

valued object
 Loss of dream of normal healthy infant
 Loss of control
 Potential loss of infant

Key Point: Grief is the core of emotional state of
NICU parents

Emotional States
Shock/Terror
 Cannot process information (especially on admission)  Rash Decisions/Disorganized
 Signs
Glazed or “deer in the headlights” look
Repeats questions already answered
Agrees to everything without questions

Emotional States
Fear
 Overwhelming vulnerability
 Unable to form attachment to infant
 Signs
Detachment, distancing, frozen

Darting eyes, rapid speech, frequent topic changes Avoid infant, leave visit early, failure to visit
Feel vulnerable, fragile, weak

Emotional States
Guilt
 Parent as cause of prematurity/illness
 Seen as punishment: “Good things happen to good people, bad things to bad people”
 Should/could have done something different
 Signs
 Dejection, self-blame, remorse, low self-esteem

 Seeking explanations “Why did this happen”

Emotional States
Depression
 Situational depression—circumstances of NICU stay
 Post-partum depression—serious seek counsel

 Signs
 Weak affect, lethargic

 Loss of appetite, neglect of self
 Sleep disturbance
 Feel despair, hopeless, powerless

 Chronic sorrow—handicapped or delayed infant

Emotional States
Anger
 Powerful emotion waiting to surface/explode
 Free-floating: directed at staff, spouse or significant other, God
 Signs
 Aggression, clenched hands
 Closed posture or open accusing

 Feel abandoned, victimized, out of control

Emotional States
Jealousy
 Jealous of nursing role in baby’s life
 Fine line between compassionate professional and surrogate parent
 Signs
 Avoid or blame professionals/insincere politeness  Compete with nurses’ knowledge of infant
 Feel left out, incompetent

Emotional States
Denial
 Deny situation seriousness
 Protective mechanism, buys time to ease into other emotional states
 We like working with these parents
 Signs
 Unrealistic expectations

 Refuse to listen to staff’s concerns
 Appear upbeat, confident, able to handle all

Emotional States
Key Point: Emotional states are fluid

not fixed. Each parent moves in and out of states at different times and often in accordance with infant’s course.

Interventions for Families in Crisis
 Ensure nurse is at bedside for first visit
 Do not overwhelm them with detailed

information
 Explain all of what you are doing
 Point out positive things about infant
 Acknowledge feelings of fear, anger, guilt, hopelessness non-judgmentally

Interventions for Families in Crisis
 Assess support systems
 Family, church, organizations
 TLC meetings—family support group
 Public sites—March of Dimes, Parents of
Premature Infants
 Caring Bridge, Face Book

Interventions for Families in Crisis
 Encourage parent journaling
 NICU-provided, personal, or blogging
 Express and explore feelings
 Record milestones
 Staff can write entries from infant

Interventions for Families in Crisis
 Assist parents in relationship with one

another/their family members
 Take time as a couple: TMCP Date Nights

 Sibling Sundays
 Sibling pictures, art work

Family-Infant Bonding
Bonding
 Gradual/reciprocal process between 2 people
 Begins with acquaintance
 Endures across time
 Mothers begins about 5th month of pregnancy
 Fathers at birth and start of caregiving

Family-Infant Bonding
Attachment
 Defined as the quality of bonding
 Quality of early bonding effects later parenting

behaviors
 Parent-infant attachment is basis of infants subsequent attachments and relationships

Family-Infant Bonding
Key Point: NICU parents are not visitors— they are parents!
Disruption of the Bonding Process
 Physical and emotional separation from infant
 Parents not being primary caregivers
 On-going threat of loss

Interventions to Promote
Bonding
Starts in delivery room
 Allow parents to see/touch infant
 Father/designee accompanies infant to NICU

 Encourage participation in care
 Developing parental role as caregiver

Promoting Bonding
Encourage participation in care
 Developing parental role as caregiver
 Provide positive reinforcement as they provide

care
 Recognize power struggles with parents/staff
 Sensitivity to touch times

Promoting Bonding
Role model nurturing behavior
 Gentle firm touch vs. light stroking
 Promoting infant’s hands to face
 Teach parents to identify infant’s stress cues
 Developmentally supportive care
 Kangaroo care
 Sibling Sundays
 Encourage personalize clothes, blankets, pictures

References
Verklan, M. T., Core, M. W., Ed. Curriculum for
Neonatal Intensive Care Nursing.
Wyly, M. V., Allen, J. Stress and Coping in the
Neonatal Intensive Care Unit.